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THE PSYCHOLOGICAL ANDPHYSIOLOGICAL EFFECT OFPERFORMING THE PRIMAL REFLEXRELEASE TECHNIQUE ON FEMALE,DIVISION I COLLEGIATE ATHLETESErika K. Vichcales

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Recommended CitationVichcales, Erika K., "THE PSYCHOLOGICAL AND PHYSIOLOGICAL EFFECT OF PERFORMING THE PRIMAL REFLEXRELEASE TECHNIQUE ON FEMALE, DIVISION I COLLEGIATE ATHLETES" (2018). Graduate Student Theses, Dissertations, &Professional Papers. 11131.https://scholarworks.umt.edu/etd/11131

i

THE PSYCHOLOGICAL AND PHYSIOLOGICAL EFFECT OF PERFORMING THE

PRIMAL REFLEX RELEASE TECHNIQUE ON FEMALE, DIVISION I

COLLEGIATE ATHLETES

By

ERIKA KATHRYN VICHCALES

B.S. Exercise Science, Michigan Technological University, MI, 2016

Professional Paper

presented in partial fulfillment of the requirements

for the degree of

Masters of Athletic Training

The University of Montana

Missoula, MT

May 2018

Approved by:

Scott Whittenburg, Dean of The Graduate School

Graduate School

Melanie McGrath, Chair

Health & Human Performance

Charles Palmer

Health & Human Performance

Karla Judge

Athletic Training

ii

Vichcales, Erika, M.A.T, May 2018 Athletic Training

The psychological and physiological effect of performing the primal reflex release

technique on female, division I collegiate athletes experiencing anxiety symptoms.

Chairperson: Dr. Melanie McGrath

Anxiety is a cognitive, behavioral, and physiological reaction to stress, and athletes have

an increased risk being in a high-stress environment. One of the effects of increased

stress on the body is a condition known as central sensitization (CS) where the central

nervous system amplifies sensory input across many organ systems causing a pain

response in normally non-painful areas or hypersensitivity to stimuli. The Primal Reflex

Release Technique (PRRT) is a manual-therapy approach for evaluating and relieving

musculoskeletal pain in patients, and is meant to facilitate a “neural reboot” of a hyper-

aroused nervous system. The purpose of this study is to examine the effect PRRT has on

the psychological and physical symptoms of anxiety. In this study 11 participants

consented to being involved and completed a baseline State Trait Anxiety Inventory

(STAI), and 4 of those were chosen to receive the treatment. Those who received the

treatment completed the STAI-Y1 form to measure state anxiety, had their heart rate and

blood pressure measured, and had a Nocioceptive Exam completed before receiving

PRRT. Immediately after the clinician performed PRRT the STAI-Y1 was repeated as

well as their physical vital signs. The athlete then completed the STAI-Y1 a third time

48-72 hours’ post-treatment, which concluded their participation in the study. A

significant difference in state anxiety (p=0.045) and heart rate (p=0.043) was found

immediately between pre-and post-treatment. Systolic blood pressure approached

significance (p=0.077) and diastolic blood pressure had no significant change. In

comparison to other holistic treatments of massage and meditation, it is suggested the

reduction in state anxiety and heart rate could be due to a relaxation mechanism that

inhibits the stress response. In conclusion, PRRT is a unique form of treatment that needs

to have further research done to understands its effects on psychology and physiology.

The evidence from this study indicates that PRRT can provide immediate relief from

symptoms of state anxiety and provides a relaxing effect decreasing the heart rate.

iii

Table of Contents

Chapter 1

Introduction ……………………..……………………………………………………………….. 1

Stress and Anxiety ………………………………………………………………………………. 2

Central Sensitization, Anxiety, and Pain………………………………………………………… 8

Methods of Treating Anxiety……………………………………………………………………. 9

Down-regulation/Primal Reflex Release Technique………………………………….………... 12

Summary ……………………………………………………………………………………….. 14

Chapter 2

Methods ………………………………………………………………………………………….16

References …………………………………………………………………………………….... 20

Chapter 3

Introduction……………………………………………………………………………………... 23

Methods ………………………………………………………………………………………… 25

Results ………………………………………………………………………………………….. 28

Discussion………………………………………………………………………………..……... 30

Limitations …………………………………………………………………………………...… 35

Conclusions……………………………………….…………………………………………….. 36

References…………..…………………………………………………………………………... 37

Appendix 1…………………………………………………………………………………….... 40

1

Chapter 1

Introduction

Anxiety is a response to stress that takes place both physically and emotionally, which

can be unsettling to those who experience it.1 Anxiety symptoms may result in significant

distress and can impair all aspects of daily living.2,3 Due to being in a high-stress environment,

athletes have shown to be at higher risk of experiencing state anxiety, which is caused by their

perception of a stressful situation. This can take a toll psychologically and physiologically

causing symptoms to manifest both emotionally and physically.3 A reason there are physical

symptoms during a stressful event may be due to the associated hyperarousal of the autonomic

nervous system when one is experiencing anxiety.4 This hyperarousal can cause fatigue, racing

heart, muscle tension, difficulty concentrating, a racing heart, or sleep disturbances.1,4,5

Anxiety can also be the cause of increased stress on the body. One of the effects of

increased stress on the body is a condition known as central sensitization (CS).6 CS is considered

a state when the central nervous system amplifies sensory input across many organ systems. This

amplification can cause hypersensitivity to stimuli and/or a pain response in normally non-

painful areas.6 There are several treatments for this pain and hypersensitivity, including treatment

known as the Down Regulation (dR) aspect Primal Reflex Release Technique (PRRT).7 Th dR

portion of PRRT is believed to reduce the hyperaroused portions of the nervous system called

“primal reflexes.” PRRT has been found to be highly effective by practitioners for treating

musculoskeletal conditions and pain, but no studies have been performed to examine whether

PRRT impacts more psychological factors, like state anxiety.7 Therefore, the purpose of this

paper is to examine the effect PRRT dR has on the psychological and physical symptoms of

anxiety.

2

Stress and Anxiety

While often used interchangeably, stress and anxiety are two separate entities. Stress is

defined as, “a state of mental or emotional strain or tension resulting from adverse or demanding

circumstances.”8 There is “good stress” (eustress) which results from the perception of

excitement or a challenge, and “bad stress” (distress) which results from an undesirable state of

chronic fatigue, worry, frustration, and the inability to cope.9 The response to stressors can have

either protective or damaging consequences on the body. This response is a result of the brain

and the body communicating through the autonomic nervous system, the endocrine system, and

the immune system.9 These systems all help the body to adapt to acute stress, but also can be the

cause of the negative effects of chronic stress.9 Stress can be the cause of fatigue and irritability

when someone feels depleted, or unable to respond to a stressor.9 Further, when there are many

stress systems in the body being activated, such as the hypothalamic-pituitary-adrenal (HPA)

axis, the autonomic nervous system, and the immunological reactivity of the individual, it can

greatly challenge homeostasis.10 The dysregulation of these systems can be an integral factor of

disease activation and progression. Stress itself is not an illness, but it does describe external

events that can contribute to pain and illness.10

Anxiety is a cognitive, behavioral, and physiological reaction to stress, which is

disruptive to the individual experiencing it.1 Anxiety causes significant disability and impairment

in occupational, relationship, and physical health.2 Anxiety is believed to be the anticipation of

what can happen in the future and is coupled with muscle tension and avoidance behaviors.1

Stress is also common in competitive athletes, and female athletes report higher anxiety rates

than males.3,11 For athletes, symptoms of anxiety may stem from a variety of sources, including

family, health, competition, financial concerns, interpersonal relationships, school, or jobs. These

3

symptoms result in significant distress and can impair daily living in school, work, play, and

interpersonal relations.3 Due to the daily perceived stress, anxiety has become a frequently

measured variable in sports psychology.12

Psychiatric disorders have become more frequent in today’s society. Studies have found

that 46.6% of the United States’ population will have a psychiatric disorder at some point in their

life, and anxiety was found in 28.85% of the population.10 The frequency of anxiety is one

reason why it is being studied in sports psychology.10 Also, the dynamic nature that encompasses

the many symptoms of anxiety is a topic of study in psychology. Anxiety is considered a

negative emotional state that is characterized by apprehension, nervousness, and worry which is

associated with physiological arousal.12 It is considered multi-dimensional because it has both

cognitive and somatic components. In addition, anxiety can be divided into two broad forms:

trait and state anxiety.13 Trait anxiety is a stable personality characteristic, defined as an

individual’s natural response to daily experiences. This means they have a predisposition to react

to situations in a consistent way.13 Trait anxiety has at least four dimensions: social evaluation,

physical danger, ambiguous, and daily routines. State anxiety is a transitionary emotion

characterized by physiological arousal and consciously perceived feelings of apprehension,

dread, and tension. State anxiety has two dimensions: cognitive worry and autonomic

emotional.13

Anxiety isn’t a “one-type-fits-all” disorder, but works on a continuous scale. People can

experience anxiety at varying amounts, ranging from low to severe.13 Some people may

experience low levels of anxiety while others will be affected to a greater degree which can

affect their social, emotional, or occupational functioning. Those who are diagnosed with an

anxiety disorder are at the severe end of the anxiety continuum, and are viewed as qualitatively

4

different from a person with a normal anxiety level. This is aligned with the psychometric

approach to anxiety assessment.13

When an individual is experiencing anxiety, there can be a range of symptoms. Physical

symptoms commonly appear when one is stressed or feeling anxious.10 Some common physical

symptoms are muscle tension, tremors, tachycardia, sweating, gastrointestinal symptoms,

genitourinary, musculoskeletal, or somatosensory complaints. McFarlane found an association

between psychiatric symptoms and perceived stress and pain.10 This could be due to psychiatric

disorders having a common neurobiology with the pathophysiology of chronic pain and a similar

mechanism of symptom manifestation. Life stressors are associated with various adverse health

outcomes, which also include somatic symptoms such as pain.10 Experiential avoidance, which is

common in those with anxiety, has been linked to risky behaviors and could be a global risk

factor for physical health problems as well. These behaviors can include substance abuse or risky

sexual behaviors that themselves have a negative impact on health.2

Anxiety not only has multiple physical repercussions, but there are emotional symptoms

as well. Some of these include an excess feeling of fear, nervousness, or worry, in addition to

avoidance behaviors.1 These symptoms occur because anxiety and fear are often associated with

a “fight or flight” reaction in the autonomic nervous system and anxiety may cause avoidance of

situations that trigger or worsen these symptoms. It has also been found that females commonly

have a “tend-and-befriend” response rather than the typical “fight or flight” response.9 Females

do tend to flee from extreme danger, but there are differences between the male and female

response via perception and behavioral stressors.9 There are also physiologic differences in the

regulation of mediators involved in the stress response. When under stress, the body goes into

what is called an “allostatic state.” This means that there is altered and sustained activity level of

5

the primary mediators that affect energetic and associated behaviors in responses to stressors.9

Allostatic states can cause wear and tear on the regulatory systems in the body since it isn’t in a

homeostatic state. When the body is in an allostatic state with a heightened alarm response due to

elevated levels of glucocorticoids and catecholamines, it may lead to an allostatic overload.9 The

overload may predispose the individual to disease and cause a state of exhaustion.9

Anxiety is often associated with hyperarousal of the autonomic nervous system.4 Anxiety

involves both physical and emotional symptoms, including restlessness, feeling on edge, fatigue,

difficulty concentrating, muscle tension, trembling, shortness of breath, a racing heart or

problems sleeping.1,4,5 The brain-body connection has been shown to manifest in physical

symptoms.9 When someone is experiencing stress, it puts physiological stressors on the bodily

systems.14 The brain changes structurally and chemically when one undergoes chronic or acute

stressors, and hormones called stress mediators are released.14 Glucocorticoids and

catecholamines are the two hormones of the “fight or flight” stress response, but there are other

stress mediators that are involved in the body’s adaption to stress. Homeostasis is a term used for

the systems that are essential for life, allostasis is what maintains these systems in a balanced

state. When a system goes beyond the limit of homeostasis, the mechanisms that create the

imbalance are known as an allostatic state. This is the result of an imbalance in the primary

mediators. For example, glucocorticoids and catecholamines are two important hormones that’s

influence allostasis. Once function of catecholamines is to increase pro-inflammatory cytokine

production, while glucocorticoids inhibit this release. However, when these hormonal mediators

are out of balance, inflammation may increase which is linked to several disease states.14 The

parasympathetic nervous symptoms also play a regulatory role because it opposes the

sympathetic nervous system and slows the heart.14

6

Stress mediators can have both protective and damaging effects on the body, resulting in

physical symptoms. These hormone mediators can be helpful or harmful, depending on the time

course of their secretion. The stress mediators themselves can cause problems with anxiety.9,14

This phenomenon has caused researchers to develop a new framework and terminology for the

link between the protective and damaging effects of biological stressors, called “allostasis” and

“allostatic overload.”9 The new terminology allows researchers to be more precise and better

explain how the essential protective and adaptive effects of physiologic mediators maintain

homeostasis. The physiologic mediators are also responsible for the cumulative effects on daily

life when they are overused or mismanaged.9 For example if the body’s alarm response is

triggered and the adrenal output of glucocorticoids and catecholamines are elevated for an

extended period, the body may go into an allostatic state which could lead to allostatic

overload.9,14 Allostasis distinguishes between the systems essential for life (homeostasis) and

what maintains the balance in these systems (allostasis).9 When the homeostatic mechanisms go

beyond the limits of homeostasis, it is considered an allostatic state. Changes in the body that

result from being in an allostatic state are known as allostatic overload, which are the cumulative

results on the physiological systems of an allostatic state.9,14

An allostatic state is when the primary mediators are in an altered or sustained activity

level in response to a changing environment or a challenge.9 An imbalance of the primary

mediators is caused by the over-production of some mediators and under-production of others,

which lead to altered physiologic function and disease. For example, an elevation of

inflammatory cytokines and decrease of cortisol is often associated with chronic fatigue

syndrome.9 When a body is in an allostatic state it can cause wear-and-tear on the regulatory

systems in the brain and body. It has been found that when stress is repeated over several weeks

7

some neurons will atrophy causing memory to be impaired while other neurons grow and fear is

enhanced.9 Chronic stress uses the same hormonal mediators as those used to suppress immune

function, which may explain some of the physical complaints of people experiencing chronic

stress.9 During allostatic states physical symptoms include memory impairment from neuron

atrophy, enhanced fear from new neuron growth, poor sleep, or ongoing stress.9 Further, some

examples of allostatic overload can include acceleration of atherosclerosis, increased risk for

cardiovascular disease and stroke, abdominal obesity, loss of minerals from bone,

immunosuppression, along with abnormal circuitry in the hippocampus, amygdala, and

prefrontal cortex.9

Those who are at risk for experiencing anxiety are not easy to identify. There are a few

risk factors that are commonly associated with anxiety such as exposure to a stressful life event,

anxiety disorders in close biological relatives, parental history of mental disorders, elevated

afternoon cortisol level in the saliva, shyness, and being female.15 Athletes may be at a greater

risk due to being in an ongoing stressful environment. Many athletes identify with increased state

anxiety during their athletic seasons for a variety of reasons, ranging from injury to looming

difficult competitions. Further, if an athlete becomes injured, anxiety may increase as well.

Players who are injured have been found to have a higher anxiety score than uninjured players.16

Further, women are found to be 56% more likely to suffer from an anxiety disorder than men

over their lifetime and are more susceptible to difficulties in their environment.17 These risk

factors make female athletes in a high stress environment at a much greater risk to experience

anxiety symptoms.16,17

8

Central Sensitization, Anxiety, and Pain

One of the consequences of prolonged stress and allostatic overload may be a condition

known as central sensitization (CS). Central sensitization is defined as a state when the central

nervous system amplifies sensory input across many organ systems.6 The increased response to

sensation includes increased plasticity of the neurons which makes the neurons more sensitive to

stimulation.6 The principal indicators of CS include hyperalgesia (hyper sensitivity to noxious

stimuli) and allodynia (pain in response to normally non-noxious stimuli). Pain results from

multiple processes which alter the function of nociceptive neurons, including increases in

membrane excitability, facilitation of synaptic strength, and decreases in inhibitory

transmission.6 The affected neurons demonstrate spontaneous activity, reduced activation

threshold and enlarged receptive fields. Hypersensitivity amplifies the sensory response elicited

by normal inputs such as innocuous stimuli and normal body sensations.6

Changes in central sensitization may be involved in multiple, poorly-understood medical

conditions. These central sensitivity syndromes (CSS) involve hyper activation of central

neurons, which leads to various synaptic and neurotransmitter/neuromodulator changes.18

Disorders that are under the category of CSS include chronic fatigue syndrome, multiple

chemical sensitivity syndrome, posttraumatic stress disorder, and tension-type headaches. Also,

psychiatric somatoform states are included with conditions such as somatization disorder,

medically unexplained symptoms, and functional pain disorders.18 These disorders share several

common symptoms such as pain, fatigue, poor sleep, sensory hyperarousal, and a high rate of

comorbid mood disorders.18 These symptoms are very similar to the symptoms of anxiety, which

suggest that both anxiety and central sensitization share important central nervous system

changes, which then affect other parts of the body. The presence of sensory hypersensitivity over

9

a wide region indicates an augmented central pain processing mechanism. Peripheral and central

sensitization have been suggested to be an underlying mechanism of chronic musculoskeletal

pain. When regarding muscle pain, it is thought that neurobiological sensitization that operates at

somatic, cognitive, and behavioral levels may increase anxiety symptoms.19 Inducing pain in an

anatomical region away from the clinical pain region is a strategy used to investigate signs of

central sensitization and/or alterations of nociception in the spinal cord.19

Central sensitization is a condition that can create a great deal of stress physiologically

and psychologically. The hypersensitivity of the nervous system creating physical pain for

individuals will also take a toll mentally. When an individual is in pain, their mental state needs

to be observed in addition to their physical state. Treatments that can help the symptoms of

central sensitization, such as referred pain, are needed and one will be discussed later in this

paper.

Methods of Treating Anxiety

Treatment for anxiety symptoms range from medication, to counseling, to alternative

therapies. Standard care approaches for health care professions treating anxiety are

psychotherapy, cognitive-behavior therapy, medication, residential treatment, complementary

and alternative treatments, and transcranial magnetic stimulation.20 Two of the most common

treatments are psychotherapy and medication.21,22 Psychotherapy, also known as “talk therapy”

has been found to be an effective treatment for those with anxiety disorders. To be effective, it

must target the individual’s specific anxieties. Though it is a common treatment, temporary

discomfort is often found due to thinking about, or confronting feared situations.22 Cognitive

Behavioral Therapy (CBT) is a type of psychotherapy used to help those with anxiety disorders.

It teaches different ways of thinking, behaving, and reacting to situations that induce anxiety or

10

fear.22 This is done via two approaches, cognitive therapy and exposure therapy. Cognitive

therapy identifies, challenges and neutralizes unhelpful thoughts, and exposure therapy confronts

the underlying fears. Exposure therapy is meant to help people engage in situations they have

been avoiding and is often used with relaxation exercises and/or imagery.15 Self-help and support

groups are also used and can be beneficial. Another form of treatment is teaching stress-

management techniques. Stress-management techniques, such as meditation, can help an

individual calm themselves and could make therapy more effective.15

The second most common treatment for anxiety is medication, which does not cure an

anxiety disorder but can help relieve symptoms.22 Patients are commonly treated using a

combination of medication and psychotherapy to produce better outcomes. The most common

medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-

blockers.22 Antidepressants are used to treat conditions such as anxiety, pain, and insomnia along

with depression. The most common form of antidepressant is a selective serotonin reuptake

inhibitor (SSRI) because it does not cause as many side effects as other classes of

antidepressants. Though they are helpful in treating mental health disorders there are common

side effects such as nausea and vomiting, weight gain, sleepiness, sexual problems, and

diarrhea.22 Anti-anxiety medications are used to help reduce symptoms such as panic attacks, or

extreme fear and worry. The most frequently used treatment for some forms of anxiety and

anxiety disorders are benzodiazepines.22 Though benzodiazepines are effective and fast-acting,

patients can build up a tolerance if taken for a long period of time or become dependent on them.

If it has been decided to remove this medication from their treatment plan then it needs to be

tapered off slowly because people can experience withdrawal symptoms or their anxiety can

return.22 Some possible side effects from the medication are nausea, blurred vision, headache,

11

confusion, tiredness, and nightmares. Beta-blockers are also used to help treat and manage the

physical side effects such as trembling, racing heartbeat, and sweating. These can be used for a

short period of time or “as needed” to reduce acute anxiety. Side effects from beta-blockers

include fatigue, cold hands, dizziness or light-headedness, and weakness.22

Though these treatments are found to be effective they are not suitable for everyone. First

it is expensive to treat anxiety and anxiety symptoms. The physical health symptoms of those

with a diagnosed anxiety disorder produce a substantial strain on the medical health system and

are considered a significant public health burden.2 One study found that the estimated total

medical costs for an individual diagnosed with an anxiety disorder to be $6,475. This estimation

includes all inpatient, outpatient, and prescription drug charges.23 In 2013 the Journal of Health

Affairs estimated that $201 billion dollars was spent in the United States on mental disorders

such as anxiety and depression.24 This is a significant amount of money being spent on

traditional treatments, and those are just the people who have a diagnosed disorder. It is common

for individuals without a diagnosed disorder to receive medication from a doctor or to see a

psychologist for treatment. This means the cost of treatment for anxiety is going to be even

higher than what has been recorded. Further, the side effects of the medications may be disabling

to a competitive athlete, and many medications are banned substances at the collegiate or

professional level (such as beta-blockers). Though psychotherapy and medication are the most

common treatments for anxiety symptoms, they may not be the best treatment for some athletes.

Between the cost and side effects of medication, and the perceived stigma of seeing a

psychologist, the likelihood of an athlete going this route for treatment of anxiety may be

unlikely. With the increase in health care costs there is a growing interest in alternative

12

treatments such as using meditation or yoga. Though alternative treatments can be considered

beneficial, it is crucial to study the effects these treatments have on anxiety.

Down-regulation/Primal Reflex Release Technique

A relatively new method of treating pain and dysfunction that may have anxiety or

central sensitization components is the down Regulation (dR) aspect of Primal Reflex Release

Technique (PRRT).7 The dR technique is a manual-therapy approach for evaluating and relieving

musculoskeletal pain in patients. It is touted as a quick treatment which provides instant relief,

and is advertised as being effective in more than 80% of patients with painful conditions.7 PRRT

practitioners state it is not uncommon for patients to feel up to 50 % improvement after the first

visit, and most patients don’t need this treatment more than several sessions to resolve their

condition.25

The dR technique is based on the belief that over-stimulation of the primal reflexes in the

body creates pain and keeps re-occurring painful patterns. These primal reflexes—withdrawal,

startle, and protective joint reflexes—are integrated into the body for survival purposes. Events

that are startling or painful can trigger these reflexes as a naturally occurring defense

mechanism.7 After the event has passed, though, these reflexes can remain in a hyper-ready state.

Having activated reflex responses over a sustained period can lead to pain patterns being

reproduced, repeated, and maintained, interfering with healing and resisting therapeutic efforts to

restore natural function. The application of dR is meant to facilitate a rapid “neural reboot” to

reset the neural control of joints, muscles, and fascia to release joint restrictions, trigger points,

and fascial restrictions. It is used to treat restricted motion, pain with or without motion, reduced

spontaneity of motion, muscle tightness, muscle tension, or muscle stiffness.7

13

John Iams, the developer of PRRT and dR, discovered how to find these reflexes and

defined them as TriggeRegions, to differentiate from the more well-known trigger points.

TriggeRegions are an area of hyperesthesia that can be found by palpating over predictable areas

while applying little to no inward pressure.25 These TriggeRegion areas have been found to have

specific patterns. It is suspected that the presence of the TriggeRegions may be a maladaptation

to stress. The TriggeRegions are located where the dura mater is attached either directly or

indirectly. The connection between dura mater and its reciprocal tension mechanism could be the

reason for the body’s quick response to this treatment.25

To start a dR, the practitioner examines these areas by palpating bilaterally in a “One

Minute Nocioceptive Exam”. This exam scans for any “up-regulated” reflexes. The exam is done

by alternately palpating on particular sites starting from the right side then assessing the left at

the TriggeRegions that Iam’s has identified.25 During the Nociceptive Exam, the practitioner is

observing to see whether the Nociceptive Startle Reflexes can be elicited. A response is

identified if the patient gasps, groans, or grimaces. The grimace has been found to be the most

frequent response.25 These signals will not all present themselves on every patient or at each

point, but the more irritable the pain pattern the greater response they will have to the exam. If no

response is noted then the practitioner can assess and note if the area is tight, tender and/or

thickened. This examination is performed pre-and post-treatment to assess how the primal

reflexes, specifically the startle and withdrawal reflex, have been affected. The dR technique is

designed to down-regulate three of the primal reflexes and uses light stimulation for about 12

seconds to reflexively and reciprocally inhibit facilitated areas.25 The technique should not cause

any discomfort to the patient, and often practitioners find minimal tight, tender, or thickened

regions after the treatment demonstrating a reduction in reflex-based excitatory nocioception. It

14

is important to note that PRRT dR does not treat everyone’s pain, and if it doesn’t work in the

first two sessions when tried should no longer be continued because it can be ruled out as a

successful treatment for that patient.25

The phenomenon of “up-regulated” primal reflexes shares similarities to central

sensitization.6,7 CS induces pain at an anatomical region different from their clinical pain site.

During the One-Minute Nocioceptive Exam the practitioner is palpating for painful sites where

there may be hypersensitivity, which is similar to what happens with CS. The similarities are

why it is thought that PRRT dR can be used to “down-regulate” the nervous system in order to

relieve physical symptoms.

Summary

The PRRT dR technique is generally used to treat pain, muscular tightness, spasm, and

hyper-active nerves that are believed to be related to the “up-regulation” of primal reflexes.

These “up-regulated” neural reflexes may occur as a result of, or concurrently with, central

sensitization. These indications also seem to mirror many of the physical symptoms of anxiety,

and prior research has shown a relationship between anxiety and the physical symptoms of

central sensitization.19 While PRRT dR is generally used to treat physical symptoms, it is

currently unknown if using a treatment like PRRT dR would alter cognitive and emotional states,

specifically those of anxiety. Thus, we want to investigate if the utilization of a treatment

designed for physical symptoms could also reduce the cognitive and emotional symptoms of

state anxiety, which may be present in patients receiving this treatment. Therefore, the purpose

of this professional paper is to determine if PRRT dR is an effective treatment for reducing the

physical and cognitive/emotional symptoms of anxiety in NCAA female athletes. Anxiety may

stem from many different sources and is difficult to overcome. Having a treatment option for

15

clinicians to use to help treat athletes with anxiety in a cost-effective way would be beneficial for

both the athlete and their sports medicine staff.

16

Chapter 2

Methods

This was a small observational study of the changes in state anxiety after a PRRT dR

treatment.

Participants: The participants were 11 members of the University of Montana women’s

intercollegiate teams, from the ages of 18-22. Participation was voluntary and participants signed

an informed consent form, approved by the Institutional Review Board. Any interested

participant completed the initial, baseline STAI form. In order to be included in the subsequent

data collections, a participant must have been selected to receive PRRT dR treatment from single

clinician (KJ) if they exhibited hypersensitivity to pain or other symptoms.

Instruments: The primary instrument used in this project was the State Trait Anxiety

Inventory (STAI). This a popular instrument used to measure signs and symptoms of anxiety

which correspond to state and trait anxiety. The STAI is a self-rating inventory that is composed

of two forms: a state form (STAI Y-1) and the trait form (STAI Y-2). To complete the STAI, the

participants answer a total of 40 verbal statements (20 in the STAI-YI and 20 in the STAI- Y2)

that use a 4-point Likert scale. The Likert scale is a subjective measurement of the experienced

intensity of a given symptom, from 1 being “not at all” to 4 being “very much so.” Some of the

items on each form are inversely scored, meaning that if the participant selected “1= not at all”,

the actual score would be a 4. These inverse items are designed to ensure the participant pays

attention to each item in the scale and responds accurately.26 The total score for each form is

determined by summing the numeric ratings of each symptom, and ranges from 20-80 points.

The higher the score the larger the anxiety level of the participant.

17

The STAI has been found to have excellent psychometric data. The internal consistency

ranges from good to excellent (Cronbach’s alpha of 0.77-0.96), a test-retest reliability of r= 0.44-

0.49, and the construct and concurrent validity are rated very good.27

Protocol: Recruitment: Recruitment took place prior to, or immediately following, a team

practice or lifting session. Permission was obtained from each coach to inform the team about the

study, and to hand out consent forms and the STAI (both the Y1 and Y2 forms). Athletes

interested in participating completed the consent form and STAI forms, then put them in an

enclosed box in the Rhinehart Athletic Training Center (RATC) graduate assistant office. This

initial STAI was used to establish a baseline for all athletes willing to participate.

Protocol: PRRT dR Intervention: The clinician, an athletic trainer with over 30 years of

experience and 4 years experience using PRRT, performed the PRRT treatment on all

participants. She routinely uses PRRT to treat pain and muscular symptoms on athletes. There

are various criteria that this clinician uses to determine if an athlete needs PRRT. These criteria

include:

• Results of the mental health screening all athletes completed during their annual

physical exam. If they had a high score, indicating concern, the athlete was

considered for PRRT treatment.

• The athlete’s primary athletic trainer believes they are a good candidate for the

treatment

• The athlete has pain in multiple TriggeRegion areas that are not associated with

an existing injury.

• The athlete is showing signs of excessive anxiety.

18

If the participant was selected to receive the PRRT dR, an appointment in the RATC was

scheduled with the clinician and primary investigator. Treatments did not occur within 1 hour of

the conclusion of a practice, team conditioning, or strength and conditioning/lifting session, in

order to prevent exertion from influencing the results.

All participants arrived to the RATC and completed the state portion of the STAI (form

Y-1) The participant then sat quietly for 15 minutes to relax and allow heart rate and blood

pressure to return to resting values. After 15 minutes, the principal investigator took the

participant’s resting heart rate using a pulse oximeter (Nonin, Onyx II 9580) and measured blood

pressure manually with a stethoscope and a sphygmomanometer. The blood pressure reading was

done on the participant’s left arm using recommended technique.28

After obtaining pre-treatment heart rate and blood pressure, the clinician performed a

One-Minute Nocioceptive Exam by palpating bilaterally at the designated TriggeRegions.

Starting at the proximal calf and moving superiorly to the head and neck, each athlete was asked

to use the Numeric Pain Rating Scale (NPRS) to vocalize the pain they experience as each point

was palpated. The NPRS is a 0-10 pain scale with 0 representing no pain and 10 representing the

worst pain imaginable. Also noted during the evaluation was the presence of a gasp or grimace

as a reaction to pain, along with the tissue texture at each TriggeRegion. After the One-Minute

Nocioceptive Exam was completed the clinician performed the PRRT dR treatment. The

treatment is completed by inciting certain reflexes in a specific order. This process began with

the palmar reflex followed by the epicranial release, frontalis release, obicularis oculi, tricranial

+ TMJ Zygomatic arch, rectus capitus posterior minor dR, hyoid flip technique, and the

digastric/mylohyoid tap (see appendix 1). After completion of the dR, palpation of each

19

TriggeRegion was repeated to evaluate change in tenderness. The evaluation and treatment took

15-20 minutes.

Once the clinician completed the PRRT dR treatment on the participant, the participant

immediately had their heart rate and blood pressure taken again by the primary investigator, in

the same room and in the same position as the pre-treatment measurement. The participant then

completed the state portion of the STAI (form Y-1). This concluded the data collection on the

day of the treatment. Finally, 48-72 hours post-treatment the participant completed the state

portion of the STAI (form Y-1) for a final time. Each participant met with the primary

investigator in the RATC, to complete the form. This concluded their participation in the study.

Data Analysis: The immediate effects of PRRT dR on state anxiety and physical vital

signs (heart rate and blood pressure), were statistically analyzed, in addition to changes in state

anxiety 2-3 days after the treatment. A repeated-measures ANOVA’s was performed to assess

the changes in the state form of the STAI (form Y-1) at 3 points: pre-treatment, immediately

post-treatment, and 48-72 hours post treatment. Repeated measured t-tests were used to compare

heart rate, systolic blood pressure, and diastolic blood pressure measurements between pre-

treatment and immediately post-treatment. Alpha was set as p≤ 0.05.

Pre-season state and trait scores of the STAI (forms Y-1 and Y-2) were compared

between the participants who were selected to undergo dR, to those who were not, to see if

participants with higher reported trait anxiety were more likely to be selected for this form of

treatment. A one-way ANOVA was performed with alpha set as p≤ 0.05.

20

References

1. Parekh R, ed. What Are Anxiety Disorders? What Are Anxiety Disorders?

https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-

disorders. Published January 2017. Accessed June 13, 2017.

2. Berghoff CR, Tull MT, Dilillo D, Messman-Moore T, Gratz KL. The role of experiential

avoidance in the relation between anxiety disorder diagnoses and future physical health

symptoms in a community sample of young adult women. Journal of Contextual

Behavioral Science. 2017;6(1):29-34. doi:10.1016/j.jcbs.2016.11.002.

3. Patel DR, Omar H, Terry M. Sport-related Performance Anxiety in Young Female

Athletes. Journal of Pediatric and Adolescent Gynecology. 2010;23(6):325-335.

doi:10.1016/j.jpag.2010.04.004.

4. Keogh E, Reidy J. Exploring the Factor Structure of the Mood and Anxiety Symptom

Questionnaire (MASQ). Journal of Personality Assessment. 2000;74(1):106-125.

doi:10.1207/s15327752jpa740108.

5. What Are Anxiety Disorders? https://www.psychiatry.org/patients-families/anxiety-

disorders/what-are-anxiety-disorders. Accessed October 20, 2017.

6. Fleming KC, Volcheck MM. Central Sensitization Syndrome and the Initial Evaluation

of a Patient with Fibromyalgia: A Review. Rambam Maimonides Medical Journal.

2015;6(2). doi:10.5041/rmmj.10204.

7. What is the Primal Reflex Release Technique™ for Pain Relief? Primal Reflex Release

Technique. http://www.theprrt.com/what-is-the-primal-reflex-release-technique-for-pain-

relief.php. Accessed October 20, 2017.

8. stress | Definition of stress in English by Oxford Dictionaries. Oxford Dictionaries |

English. https://en.oxforddictionaries.com/definition/stress. Accessed October 20, 2017.

9. McEwen BS. Stressed or stressed out: What is the difference? Journal of Psychiatry

Neuroscience. 2005;30(5):315-317.

10. Mcfarlane AC. Stress-related musculoskeletal pain. Best Practice & Research Clinical

Rheumatology. 2007;21(3):549-565. doi:10.1016/j.berh.2007.03.008.

11. Masten R, Tusak M, Tusak M. Identity and anxiety in athletes. Kinesiology.

2006;38(2):126-135. doi:10.1037/e548052012-583Hansberger B, Baker R, May J,

12. Hoover SJ, Winner RK, McCuthchan H, et al. Mood and Performance Anxiety in High

School Basketball Players: A Pilot Study. International Journal of Exercise Science.

2017;10(4):604-618.

21

13. Endler NS, Kocovski NL. State and trait anxiety revisited. Journal of Anxiety Disorders.

2001;15(3):231-245. doi:10.1016/s0887-6185(01)00060-3.

14. McEwen BS. Central effects of stress hormones in health and disease: understanding the

protective and damaging . European Journal of Pharmacology. 583:174-185.

15. Anxiety Disorders. National Institute of Mental Health.

https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml. Accessed October

20, 2017.

16. Junge A, Feddermann-Demont N. Prevalence of depression and anxiety in top-level male

and female football players. BMJ Open Sport & Exercise Medicine. 2016;2(1).

doi:10.1136/bmjsem-2015-000087.

17. Schaal K, Tafflet M, Nassif H, et al. Psychological Balance in High Level Athletes:

Gender-Based Differences and Sport-Specific Patterns. PLoS ONE. 2011;6(5).

doi:10.1371/journal.pone.0019007.

18. Batheja S, Nields JA, Landa A, Fallon BA. Post-Treatment Lyme Syndrome and Central

Sensitization. The Journal of Neuropsychiatry and Clinical Neurosciences.

2013;25(3):176-186. doi:10.1176/appi.neuropsych.12090223.

19. Sjors A, Larsson B, Persson AL, Gerdle B. An increased response to experimental

muscle pain is related to psychological status in women with chronic non-traumatic neck-

shoulder pain. BMC Musculoskeletal Disorders. 2011;230(12).

20. Facts & Statistics. Anxiety and Depression Association of America, ADAA.

https://adaa.org/about-adaa/press-room/facts-statistics. Accessed October 20, 2017.

21. Anxiety. Mayo Clinic. https://www.mayoclinic.org/diseases-

conditions/anxiety/symptoms-causes/syc-20350961. Published August 16, 2017.

Accessed October 20, 2017.

22. Mental Health Medications. National Institute of Mental Health.

https://www.nimh.nih.gov/health/topics/mental-health-

medications/index.shtml#part_149857. Accessed October 20, 2017.

23. Marciniak MD, Lage MJ, Dunayevich E, et al. The cost of treating anxiety: the medical

and demographic correlates that impact total medical costs. Depression and Anxiety.

2005;21(4):178-184. doi:10.1002/da.20074.

24. Roehrig C. Mental Disorders Top The List Of The Most Costly Conditions In The United

States: $201 Billion. Health Affairs. 2016;35(6):1130-1135.

doi:10.1377/hlthaff.2015.1659.

22

25. Iams J. Primal Reflex Release Technique. Primal Reflex Release Technique Seminar .

2013.

26. Spielberger C. Manual for the State-Trait Anxiety Inventory. rev. ed. Consulting

Psychologists Press; Palo Alto (CA): 1983.

27. Rossi V, Pourtois G. Transient state-dependent fluctuations in anxiety measured using

STAI, POMS, PANAS or VAS: a comparative review. Anxiety, Stress & Coping.

2012;25(6):603-645. doi:10.1080/10615806.2011.582948.

28. Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T,

Sheps SG, Roccella EJ; Subcommittee of Professional and Public Education of the

American Heart Association Council on High Blood Pressure Research.

Recommendations for blood pressure measurement in humans and experimental animals:

Part 1: blood pressure measurement in humans: a statement for professionals from the

Subcommittee of Professional and Public Education of the American Heart Association

Council on High Blood Pressure Research. Hypertension. 2005;45(1):142-61.

29. Endler NS, Cox BJ, Parker JD, Bagby RM. Self-reports of depression and state anxiety:

Evidence for differential assessment. J Pers Soc Psychol. 1992; 63(5):832-838

23

Chapter 3: Manuscript

Introduction

Anxiety is a cognitive, behavioral, and physiological reaction to stress causing significant

disability and impairment in occupational, relationship and physical health.1,2 Anxiety is the

anticipation of what can happen in the future and is coupled with muscle tension and avoidance

behaviors. Competitive athletes and female athletes, report higher anxiety rates than males.3,4 For

athletes, symptoms of anxiety may stem from a variety of sources, including family, health,

competition, financial concerns, interpersonal relationships, school or jobs. These symptoms

result in significant distress and may impair daily living in school, work, play, and interpersonal

relations.3 Due to the impact psychological factors have on mood and performance, anxiety has

become a frequently measured variable in sports psychology.5 The impact these factors have on

enjoyment of sport, continued participation, and self-efficacy drives the research to explore the

components of anxiety.5

Diagnoses of psychiatric disorders have increased in recent years. 46.6% of the United

States’ population will be a diagnosed with a psychiatric disorder at some point in their life.

Anxiety disorders are found in 28.85% of the population.6 Further, women are found to be 56%

more likely to suffer from an anxiety disorder than men over their lifetime and are more

susceptible to difficulties in their environment.7 These data points only reflect diagnosed

disorders, and do not represent the millions of others who experience symptoms of anxiety that

do not meet diagnostic criteria. At lease 30% of collegiate athletes report symptoms of anxiety at

the beginning of the season.8 Therefore, female athletes in a high stress environment at a much

greater risk of experiencing anxiety symptoms.7,9

24

Chronic anxiety and stress may cause hypersensitivity to stimuli or a pain response in

normally non-painful areas, a condition called “central sensitization” (CS).10,11 Patients with CS

often report chronic pain, as well as emotional and psychological symptoms including anxiety,

fatigue, and depression.10 Various treatments are available for the symptoms of CS, but these

treatments are often time-intensive, expensive, or come with undesirable side effects. Often, they

do not adequately treat the symptoms experienced by individuals with CS.10

The down regulation (dR) aspect of primal reflex release technique (PRRT) is a manual

therapy approach to evaluate and relieve musculoskeletal pain in patients, including those who

display characteristics of CS. The “primal reflexes”- withdrawal, startle, and protective joint

reflexes—are activated when a startling or painful event occurs.12 These reflexes are a defense

mechanism against threats and help prevent injury. However, these reflexes may remain in a

hyper-ready state after the threat has passed, which creates pain, muscle tension, and

hypersensitivity to stimuli. There is limited research on this technique, although case studies

demonstrate decreased pain and muscle tension in patients treated with PRRT dR.11

While PRRT is generally used to treat pain, muscular tightness, and hypersensitivity no

research has explored if using PRRT dR will change other symptoms that often occur with pain,

including the physical and psychological symptoms common with anxiety.11 Therefore, the

purpose of this research study was to determine if PRRT dR is an effective treatment for

reducing psychological and physical symptoms of anxiety in NCAA Division I female athletes.

The immediate effects of PRRT dR on state anxiety and physical vital signs (heart rate and blood

pressure) were assessed, in addition to changes in state anxiety that remained 2-3 days after the

treatment.

25

Methods

This was a small observational study of the changes in state anxiety after a PRRT dR

treatment.

Participants: The participants were 11 members of the University of Montana women’s

intercollegiate teams, from the ages of 18-22. Participation was voluntary and participants signed

an informed consent form, approved by the Institutional Review Board. Any interested

participant completed the initial, baseline STAI form. In order to be included in the subsequent

data collections, a participant must have been selected to receive PRRT dR treatment from single

clinician (KJ) if they exhibited hypersensitivity to pain or other symptoms.

Instruments: The primary instrument used in this project was the State Trait Anxiety

Inventory (STAI). This a popular instrument used to measure signs and symptoms of anxiety

which correspond to state and trait anxiety. The STAI is a self-rating inventory that is composed

of two forms: a state form (STAI Y-1) and the trait form (STAI Y-2). To complete the STAI, the

participants answer a total of 40 verbal statements (20 in the STAI-YI and 20 in the STAI- Y2)

that use a 4-point Likert scale. The Likert scale is a subjective measurement of the experienced

intensity of a given symptom, from 1 being “not at all” to 4 being “very much so.” Some of the

items on each form are inversely scored, meaning that if the participant selected “1= not at all”,

the actual score would be a 4. These inverse items are designed to ensure the participant pays

attention to each item in the scale and responds accurately.26 The total score for each form is

determined by summing the numeric ratings of each symptom, and ranges from 20-80 points.

The higher the score the larger the anxiety level of the participant.

26

The STAI has been found to have excellent psychometric data. The internal consistency

ranges from good to excellent (Cronbach’s alpha of 0.77-0.96), a test-retest reliability of r= 0.44-

0.49, and the construct and concurrent validity are rated very good.27

Protocol: Recruitment: Recruitment took place prior to, or immediately following, a team

practice or lifting session. Permission was obtained from each coach to inform the team about the

study, and to hand out consent forms and the STAI (both the Y1 and Y2 forms). Athletes

interested in participating completed the consent form and STAI forms, then put them in an

enclosed box in the Rhinehart Athletic Training Center (RATC) graduate assistant office. This

initial STAI was used to establish a baseline for all athletes willing to participate.

Protocol: PRRT dR Intervention: The clinician, an athletic trainer with over 30 years of

experience and 4 years experience using PRRT, performed the PRRT treatment on all

participants. She routinely uses PRRT to treat pain and muscular symptoms on athletes. There

are various criteria that this clinician uses to determine if an athlete needs PRRT. These criteria

include:

• Results of the mental health screening all athletes completed during their annual

physical exam. If they had a high score, indicating concern, the athlete was

considered for PRRT treatment.

• The athlete’s primary athletic trainer believes they are a good candidate for the

treatment

• The athlete has pain in multiple TriggeRegion areas that are not associated with

an existing injury.

• The athlete is showing signs of excessive anxiety.

27

If the participant was selected to receive the PRRT dR, an appointment in the RATC was

scheduled with the clinician and primary investigator. Treatments did not occur within 1 hour of

the conclusion of a practice, team conditioning, or strength and conditioning/lifting session, in

order to prevent exertion from influencing the results.

All participants arrived to the RATC and completed the state portion of the STAI (form

Y-1) The participant then sat quietly for 15 minutes to relax and allow heart rate and blood

pressure to return to resting values. After 15 minutes, the principal investigator took the

participant’s resting heart rate using a pulse oximeter (Nonin, Onyx II 9580) and measured blood

pressure manually with a stethoscope and a sphygmomanometer. The blood pressure reading was

done on the participant’s left arm using recommended technique.28

After obtaining pre-treatment heart rate and blood pressure, the clinician performed a

One-Minute Nocioceptive Exam by palpating bilaterally at the designated TriggeRegions.

Starting at the proximal calf and moving superiorly to the head and neck, each athlete was asked

to use the Numeric Pain Rating Scale (NPRS) to vocalize the pain they experience as each point

was palpated. The NPRS is a 0-10 pain scale with 0 representing no pain and 10 representing the

worst pain imaginable. Also noted during the evaluation was the presence of a gasp or grimace

as a reaction to pain, along with the tissue texture at each TriggeRegion. After the One-Minute

Nocioceptive Exam was completed the clinician performed the PRRT dR treatment. The

treatment is completed by inciting certain reflexes in a specific order. This process began with

the palmar reflex followed by the epicranial release, frontalis release, obicularis oculi, tricranial

+ TMJ Zygomatic arch, rectus capitus posterior minor dR, hyoid flip technique, and the

digastric/mylohyoid tap (see appendix 1). After completion of the dR, palpation of each

28

TriggeRegion was repeated to evaluate change in tenderness. The evaluation and treatment took

15-20 minutes.

Once the clinician completed the PRRT dR treatment on the participant, the participant

immediately had their heart rate and blood pressure taken again by the primary investigator, in

the same room and in the same position as the pre-treatment measurement. The participant then

completed the state portion of the STAI (form Y-1). This concluded the data collection on the

day of the treatment. Finally, 48-72 hours post-treatment the participant completed the state

portion of the STAI (form Y-1) for a final time. Each participant met with the primary

investigator in the RATC, to complete the form. This concluded their participation in the study.

Data Analysis: The immediate effects of PRRT dR on state anxiety and physical vital

signs (heart rate and blood pressure), were statistically analyzed, in addition to changes in state

anxiety 2-3 days after the treatment. A repeated-measures ANOVA’s was performed to assess

the changes in the state form of the STAI (form Y-1) at 3 points: pre-treatment, immediately

post-treatment, and 48-72 hours post treatment. Repeated measured t-tests were used to compare

heart rate, systolic blood pressure, and diastolic blood pressure measurements between pre-

treatment and immediately post-treatment. Alpha was set as p≤ 0.05.

Pre-season state and trait scores of the STAI (forms Y-1 and Y-2) were compared between the

participants who were selected to undergo dR, to those who were not, to see if participants with

higher reported trait anxiety were more likely to be selected for this form of treatment. A one-

way ANOVA was performed with alpha set as p≤ 0.05.

Results

Of the athletes who were eligible to be a part of the study, 11 consented to participation,

4 of which received the treatment. The participants’ age ranged from 18-22 years old with a

29

mean of 21.00 0.816 years, and from the women’s volleyball (n=2), soccer (n=3), basketball

(n= 4), tennis (n=1), and softball (n=1) teams. Of these 11 participants, 4 received PRRT dR

treatment. These athletes were female, ranging from 18-20 years old with a mean age of was

19.50 1.0 years, and from the women’s volleyball (n=2) and soccer (n=2) teams.

No significant difference was found comparing the STAI-Y1 (F(1,9) = 0.238, p= 0.637)

and for STAI-Y2 (F(1,9) = 0.184, p= 0.678) scores between the participants who did receive

treatment and who did not (see Table 1.)

Table 1: STAI-Y1 and STAI-Y2 comparison for athletes who received PRRT vs. the

control group

Variable PRRT mean s.d. Control mean s.d. F(dF) p-value

STAI-YI 32.50 13.229 35.68 9.668 F(1,9) = 0.238 p= 0.637

STAI-Y2 35.75 9.946 38.14 8.335 F(1,9) = 0.184 p= 0.678

The changes in STAI-Y1 values pre-treatment, post-treatment, and 42-72 hours post-

treatment approach significance (F(2,6)= 4.751, p = 0.058) (see Table 2). Due to the exploratory

nature of the study, a paired t-test was performed to assess the pre-treatment to post-treatment

changes in STAI-Y1 a posteriori.

Table 2: Comparing STAI-Y1 pre-treatment, post-treatment, and 48-72 hours post-

treatment.

Variable Pre-Tx mean s.d. Post-Tx mean

s.d.

48-72 hours

mean s.d. F (df) p-value

STAI-Y1 31.25 5.909 23.75 2.363 29.00 7.703 F(2,6)= 4.751 p = 0.058

The STAI-Y1 (t3=3.326, p = 0.045) and heart rate measurements (t3= 3.368, p = 0.043)

showed a significant change post-treatment. The systolic blood pressure approached significance

30

(t3= 2.646, p = 0.077). The diastolic blood pressure did not change (t3= 1.169, p = 0.327). Table

3 presents the heart rate, systolic and diastolic blood pressure, and STAI-Y1 scores pre and post-

treatment.

Table 3: Analysis of STAI-Y1, heart rate, systolic blood pressure, and diastolic pressure

before and after treatment.

Variable Pre-Tx mean

s.d.

Post-Tx mean

s.d. t (df) p-value

STAI-Y1 31.25 5.909 23.75 2.363 t3=3.326 p = 0.045

HR 76.00 17.701 63.75 13.574 t3= 3.368 p = 0.043

Systolic BP 114.75 3.948 111.25 2.986 t3= 2.646 p = 0.077

Diastolic BP 69.00 6.831 65.75 1.50 t3= 1.169 p = 0.327

Discussion

The purpose of this study was to examine the psychological and physiological effects of

PRRT. The investigators determined that PRRT dR does produce changes in decreased heart rate

and state anxiety. The decrease in heart rate and state anxiety symptoms from pre-treatment to

immediately post-treatment, indicate changes in both psychological state and physiology.

State and trait anxiety scores were compared to normative values for female college

students, to compare if female athletes who volunteered for this study had similar reported levels

of trait anxiety.16 In Endler’s study of undergraduate college students, the state anxiety for

female students was measured at 36.23 11.23 and trait anxiety was measured 42.31 10.60.16

The participants who participated in this study had slightly lower trait and state anxiety levels,

regardless of group. The difference in scores could be due to several reasons. First, there were

only eleven participants in this study, thus small sample size may influence the results. Also, it is

31

possible that those who filled out the consent forms were less anxious than those who did not.

This consent forms were handed out to 69 athletes, so only 6.27% of the athletes decided to

participate. It is a possibility that those who turned in the surveys to participate did not believe

they had any symptoms of anxiety, and thus were more comfortable agreeing to be a part of the

study.

Second, STAI baseline scores were not used as a determining factor for if the participant

would receive treatment. Due to the STAI scores not being used as inclusion criteria for

receiving treatment, it indicates that other factors helped decide if an athlete was to receive

treatment such as hypersensitivity or muscle tension.

There have been no experimental studies using PRRT dR, thus direct comparisons to

published research is no possible. However, comparing the results of PRRT dR to other, similar

manual therapy techniques provides an opportunity to explore similarities and differences to

more established techniques. Studies of facial massage, which also involves working with facial

structures, found a significant reduction in anxiety which they attributed to “sleep induction”

associated with a deep sense of relaxation and changes in brain wave activity, similar to what

occurs just prior to sleep.17,18,19 Massage, including facial massage, is concluded to have this

calming effect on the physiology.17

The study done by Hayamata used an ECG to monitor heart rate variability as well as the

STAI to monitor anxiety symptoms in conjunction with a facial massage.19 Hatayama looked at

anxiety levels and the activity of the autonomic nervous system in 32 healthy Japanese women

with a mean age of 28.5 years old. This study found that the low and high frequency heart ratio

(LF/HF ratio) significantly increased after the massage, though the heart rate remained the

same.19 This is significant because the LF/HF ratio represents sympathetic nervous activity. The

32

investigators speculated that the increased sympathetic nervous activity after the facial massage

could be a positive stress reaction to the treatment, often referred to as eustress, and that eustress

may increase sympathetic nervous system output despite no perceived distress. The study also

found that the STAI anxiety score significantly declined after a facial massage.19 The STAI

scores went from 36.25 1.33 to 28.25 1.04 after the massage (P<0.001). The investigators

discussed that the decrease in anxiety scores and the increase in sympathetic nervous activity

could be considered refreshment instead of relaxation.19 Facial massage may cause similar

changes as PRRT dR, as several of the reflexes that are stimulated during the treatment are on

the face and neck. This could be why facial massage causes similar changes to the observed

changes after PRRT dR, because it affects the same area.

A study done by Buttagat looked at the therapeutic effects of traditional Thai massage

(TTM) on various factors including anxiety.21 In this study, the participants received 9 massage

treatments over the course of 3 weeks. Anxiety was measured using the STAI state form pre-

treatment, immediately post-treatment on the first day, one day after the last treatment, and 2

weeks after the last treatment.21 This study found a significant decrease in anxiety at every

measurement point. The STAI mean baseline was 47.4, the post-test 1 mean was 36.0, the post-

test 2 was 31.5, and the post-test 3 was 34.3. The significant decrease from baseline to post-

treatment in this study is comparable to the 7.5 point drop observed after PRRT dR. Anxiety

continued to decrease after completion of the 9 massage treatments, which may indicate that if

PRRT dR was completed over a series of sessions rather than just one, single treatment it may

demonstrate similar results. Buttagat and colleagues also found a decrease in pain intensity and

muscle tension and an increase in pressure pain threshold, and these improvements remained up

to 2-weeks post-treatment.21 One reason the researchers thought TTM decreased anxiety was due

33

to the relaxation response that occurs during treatment.22 When this occurs the stress response is

inhibited and anxiety levels are decreased.22 The decrease in stress also produces an increased

vagal outflow and diminished activity of the sympathetic nervous system.23 These mechanisms

can all be attributed to an immediate decrease in anxiety. There is a possibility that the reduction

in state anxiety after PRRT dR treatment may be due to a similar relaxation mechanism

experienced during TTM. This may provide one reason why practitioners of PRRT dR believe

that it is an effective treatment for pain.

Meditation is gaining attention by the medical community today as a method of reducing

anxiety. Lee and colleagues studied 46 patients with anxiety disorder and assigned them to an 8-

week clinical trial either being a part of a meditation-based stress management program or an

anxiety disorder education program.24 The STAI along with other anxiety measures were used as

a measure outcome at 0, 2, 4, and 8 weeks into the program. The meditation-based stress

management group showed significant improvement in both state and trait scores.24 Researchers

concluded that the meditation-based stress management program can be an effective treatment in

relieving anxiety symptoms in those who have anxiety disorders.24 The STAI-Y1 showed that the

meditation group decreased their anxiety score during every measurement taken in the study.

Between baseline and 2 weeks into the program, mean state anxiety decreased 5.6 points, from

week 2 to week 4 there was a 1.3 point decrease, from week 4 to 8 there was a 0.7 point

decrease, and from baseline to 8 weeks there was a 7.6 point decrease.24 This is important

because the 7.6 point decrease in state anxiety from the meditation-based stress management

program occurred after 8 weeks, where PRRT dR had a 7.5 point decrease in state anxiety in

about a 20 minute treatment session.24 This suggests that PRRT dR may be as effective as

meditation is for state anxiety for those suffering from anxiety symptoms, but it provides relief

34

much faster than meditation does. However, the decrease in STAI did not persist after PRRT dR,

unlike that seen in the meditation studies. This treatment comparison indicates that more research

should be completed to indicate if PRRT dR may be comparable, or perhaps used with,

meditation or other forms of stress reduction.24

Another study, done by Edwards, compared single bouts of aerobic exercise or

meditation on state anxiety in young adults.25 State anxiety was measured using the STAI before

and after the selected intervention. This study found that state anxiety significantly decreased

from baseline to post-intervention in meditation (P=0.002), meditation then walk (P=0.03), and

walk then meditation groups (P=0.002), but not in the walk (P=0.75) or control (P=0.45)

groups.25 The mean STAI score differences between baseline and after meditation (n=4.6), after

a walk then meditation (n=5.6), and after meditation then a walk was (n=3.1).25 The difference

between STAI scores pre and post treatment is actually greater post PRRT dR than post various

methods of meditation. Edwards found that meditation may be a preferred method of relieving

anxiety symptoms in comparison to aerobic exercise.25 The state anxiety scores post PRRT dR

were actually lower than after meditation but the difference between pre and post treatment is

greater after PRRT dR, which indicates that PRRT dR has similar affects neurologically.

A systematic review done by the American Heart Association, examined the

neurophysiological and neuroanatomical changes after meditation.26 A 2-month mindfulness

meditation program resulted in increased left-sided anterior brain electrical activation.27 This

electrical activation is a pattern associated with positive affect and emotion, and these changes

were only seen in the group that practiced meditation.27 This study did not find consistent data on

how heart rate is affected by meditation, but it did show that blood pressure often decreased after

meditation. PRRT dR appeared to acutely change both anxiety and heartrate, which may indicate

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that the neurophysiologic changes associated with meditation are slightly different than those

caused by PRRT dR. The fact that PRRT dR also lead to a significant decrease to heart rate

indicates that PRRT dR affects the cardiovascular system more so than meditation, while

meditation appears to create longer-lasting decreases in anxiety. Future studies should examine if

repeated treatments of PRRT dR can cause a similar long-lasting change in state anxiety, and

perhaps be an alternative method for changing both the physical and psychological symptoms of

anxiety.

Limitations

There are many limitations that came with this study such as investigator error,

participant bias, and limited study size. The investigator measured blood pressure manually and

used a pulse oximeter to measure heart rate. There can be some error in these methods,

particularly manual blood pressure, which could skew the results. There could be participant bias

due to the subjective nature of the STAI, especially if the participant is under the impression they

should “feel better” after the treatment. Another limitation is some of the participants in the study

had received the treatment from this clinician before and were potentially more comfortable

which could skew the STAI scores. The number of participants in the study is also a major

limitation. Only 6.7% of those who received consent forms filled them out, and not everyone

who consented received the treatment. Coordinating treatment time with athletes was difficult

due to the variability of their schedules and the many commitments as a student athlete. Often,

the clinician delivering the treatment was out-of-town when a participant had time to receive a

treatment, or vice versa. Class and practice schedules also made scheduling treatment times

difficult. This difficulty in coordinating schedules did prevent some athletes who could have

received the treatment from actually receiving it. Also, the pain data from the Nocioceptive

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Exam pre- and post-treatment was not included in this study, and in future studies it should be

analyzed. A larger sample size would be very beneficial in understanding the effectiveness of

PRRT dR psychologically and physiologically.

Conclusion

In conclusion, PRRT dR is a unique form of treatment that needs to have further research

done to understand its effects on psychology and physiology. The evidence from this exploratory

study indicates that PRRT dR can provide immediate relief from state anxiety symptoms, and

can help decrease the patient’s heart rate providing a relaxing effect. This study should be done

on a larger number of athletes, specifically those who had diagnosed anxiety disorders or often

report anxiety symptoms. PRRT dR may be a comparable form of treatment for state anxiety in

comparison to other holistic treatments such as meditation and massage. Clinicians may consider

using PRRT dR to help patients who experience anxiety symptoms, or to assist patients during a

stressful, short term situation.

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Appendix 1: PRRT Techniques

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